1. 2. 3. 4. 5. 6. Votes rejected A-L Votes rejected M Votes rejected N-Z Total votes rejected Total valid and rejected votes cast I hereby certify that the above is a correct statement of all votes counted at the abovementioned polling station (Signed)……………………………………….. Presiding Officer Dated this………………….…. day of……………………………………., 20…………… Signatures of candidates/election agents (please specify designation opposite signature) (Signed)……………………………………….. (Signed)……………………………………….. (Signed)……………………………………….. (Signed)……………………………………….. (Signed)……………………………………….. (Signed)……………………………………….. - 32 -